John Engberg

Staff turnover and quality of care in nursing homes.

Purpose:In this work, the association between nurse aide (NA) plus licensed practical nurse (LPN) and registered nurse (RN) turnover and quality indicators in nursing homes is examined. Design and Methods:Indicators of care quality used are the rates of physical restraint use, catheter use, contractures, pressure ulcers, psychoactive drug use, and certification survey quality of care deficiencies. In addition, we used a quality index combining these indicators. Turnover information came from primary data collected from 354 facilities in 4 states and other information came from the 2003 Online Survey, Certification and Reporting data. The turnover rates were grouped into 3 categories, low, medium, and high, defined as 0% to 20%, 21% to 50%, and greater than 50% turnover, respectively. Results:The average 1-year turnover rates identified in this study were high at 85.8% for NAs and LPNs and 55.4% for RNs. Multivariate analysis shows that decreases in quality are associated with increases in RN turnover, especially increases from low-to-moderate levels of turnover, and with increases in NA and LPN turnover, especially increases from moderate-to-high levels of turnover. Implications:These findings are significant because the belief that staff turnover influences quality is pervasive. The cross-sectional results are only able to show associations, nonetheless, few empirical studies in the literature have shown this relationship.

Dynamic effects of self-efficacy on smoking lapse and relapse.

Self-efficacy (SE) is thought to be critical to success in smoking cessation both as an individual difference and as a dynamic process after a quit attempt. In this study, 214 smokers used palm-top computers to record day-to-day variations in SE during 4 weeks after quitting. SE remained at high and stable levels prior to a 1st lapse but decreased and became more variable thereafter. The authors used event history models with time-varying covariates to assess the effect of daily SE on lapse and relapse risk. Daily SE measures predicted an initial lapse on the subsequent day. However, this relationship was accounted for by stable baseline differences in SE (assessed by questionnaire), rather than by day-to-day dynamics in SE. Progression from 1st lapse to relapse was also examined. In this instance, daily SE predicted subsequent relapse risk, even when baseline SE and concurrent smoking were accounted for, suggesting the importance of SE dynamics for this stage of the relapse process.

Enterprise zones and local employment: evidence from the states’ programs

Abstract Many states respond to deteriorating economic conditions in their inner cities and rural communities by establishing geographically targeted tax incentives. In this paper, we examine the impact of several of these Enterprise Zone (EZ) programs on local employment. The results show that the EZ programs do not have a significant impact on local employment. Program impact does not depend on the monetary amount of the incentives and or on specific features of program design. These conclusions are constant across two econometric approaches to controlling for the non-random placement of zones and stand up to a wide variety of sensitivity analyses.

Scale and scope economies among health maintenance organizations

We examine scale and scope economics among Group and IPA Health Maintenance Organizations (HMOs) over the period 1988 to 1991 using a national sample of HMOs. We allow for the multiproduct nature of HMO production by estimating the cost of producing a member month of non-Medicare and Medicare coverage, and we examine the effect of HMO market structure on costs. We find that HMOs benefit from scale economies. There are scope diseconomies associated with providing both non-Medicare and Medicare products. Group HMOs in more competitive markets have lower costs but IPA costs are not affected by competition.

The opportunity costs of informal elder-care in the United States: new estimates from the American Time Use Survey.

OBJECTIVES To provide nationally representative estimates of the opportunity costs of informal elder-care in the United States. DATA SOURCES Data from the 2011 and 2012 American Time Use Survey. STUDY DESIGN Wage is used as the measure of an individuals value of time (opportunity cost), with wages being imputed for nonworking individuals using a selection-corrected regression methodology. PRINCIPAL FINDINGS The total opportunity costs of informal elder-care amount to

The Health Consequences of Using Physical Restraints in Nursing Homes

522 billion annually, while the costs of replacing this care by unskilled and skilled paid care are

Have Nursing Home Compare quality measure scores changed over time in response to competition

221 billion and

Factors associated with increasing nursing home closures.

642 billion, respectively. CONCLUSIONS Informal caregiving remains a significant phenomenon in the United States with a high opportunity cost, although it remains more economical (in the aggregate) than skilled paid care.

The Role of Drug Markets and Gangs in Local Homicide Rates

Background:Using a national longitudinal sample of nursing homes residents (N = 264,068), we examine whether physical restraint use contributes to subsequent physical or psychological health decline. Methods:The minimum data set, the on-line survey certification and recording system, and the area resource file were the data sources used. This data represented the period of 2004 and 2005. To control for the difference in characteristics between residents who were subsequently physically restrained and who were not, we use a propensity score matching method. Results:For all outcomes examined (except depression), that is, behavior issues, cognitive performance, falls, walking dependence, activities of daily living, pressure ulcers, and contractures, were all significantly worse for restrained residents compared with matched residents who were not restrained. Discussion:Physical restraint use represents poor clinical practice, and the benefits to residents of further reducing physical restraint use in nursing homes are substantial.

Nursing Home Administrators' Opinions of the Resident Safety Culture in Nursing Homes

Background: Currently, the Centers for Medicare and Medicaid Services report on 15 Quality Measures (QMs) on the Nursing Home Compare (NHC) website. It is assumed that nursing homes are able to make improvements on these QMs, and in doing so they will attract more residents. In this investigation, we examine changes in QM scores, and whether competition and/or excess demand have influenced these change scores over a period of 1 year. Methods: Data come from NHC and the On-line Survey Certification And Recording (OSCAR) system. QM change scores are calculated using values from January 2003 to January 2004. A series of regression analyses are used to examine the association of competition and excess demand on QM scores. Results: Eight QMs show an average decrease in scores (ie, better quality) and six QMs show an average increase in scores (ie, worse quality). However, for 13 of the 14 QMs these average changes averaged less than 1%. The regression analyses show an association between higher competition and improving QM scores and an association between lower occupancy and improving QM scores. Conclusion: As would be predicted based on the market-driven mechanism underlying quality improvements using report cards, we show that it is in the most competitive markets and those with the lowest average occupancy rates that improvements in the QM scores are more likely.